Clinical Quality and Regulatory Specialist

This is a fully remote position, open to applicants in Florida.

📋 Description

• Assist in ensuring compliance across Health Services, which includes Appeals and Grievances, Case Management, Utilization Management, and Medical Pharmacy.

• Oversee and report on operational activities and delegated functions within Health Services.

• Work collaboratively with Health Services leadership and Compliance on regulatory and delegated tasks.

• Create and execute internal audit processes.

• Conduct routine and ad hoc compliance monitoring, documenting findings accordingly.

• Oversee vendor and subcontractor delegation processes.

• Supervise staff involved in utilization management decision-making on at least a monthly basis.

• Act as a liaison with Compliance and Fraud, Waste, and Abuse teams.

• Stay informed about Federal, State, organizational, and industry regulations, standards, best practices, and State contract language.

• Evaluate, interpret, and communicate the implications of new and updated requirements, providing training as needed.

• Address compliance-related questions from both internal and external auditors.

• Prepare, present, and submit necessary reports to relevant agencies and organizational committees.

• Engage in internal and external meetings, committees, and audits as a presenter or representative of Health Services.

• Implement LEAN methodologies and principles of quality improvement.

• Utilize visual boards and daily huddles to track KPIs and identify opportunities for improvement.

• Monitor, develop, and update policies, procedures, training materials, letters, handbooks, and other internal documents.

• Facilitate education and onboarding programs for employees, vendors, and subcontractors.

• Provide backup support for other Health Services staff as permitted by licensure.

• Participate in assigned committees, teams, and task forces.

• Represent Health Services both internally and externally.

• Adhere to privacy and HIPAA regulations while performing additional assigned duties.

⛳️ Requirements

• A minimum of six years of nursing or clinical behavioral health experience, with diverse healthcare exposure.

• At least two years of experience in the insurance industry.

• Must be a Registered Nurse, Licensed Clinical Psychologist, Licensed Clinical Social Worker, or a comparable behavioral health professional with substantial experience and/or credentials.

• Possess a current unrestricted state license(s).

• Certification as a Certified Case Manager (CCM) preferred within two years, or completion of 60 CEUs in Utilization Management focused areas.

• In-depth knowledge of medical procedures, diagnoses, care modalities, ICD-10, DSM-IV, and CPT codes.

• Understanding of health insurance and State-mandated benefits.

• Awareness of contractual benefits and options available within and beyond those benefits.

• Capability to utilize computerized systems for data entry and retrieval.

• Knowledge of patient confidentiality, privacy, and health records security.

• Expertise in strategy deployment, daily operations, visual management, operational enhancement, and auditing.

• Up-to-date clinical knowledge base and certification.

• Ability to function independently with minimal supervision and collaboratively within a team environment.

• Proficient in reading and comprehending written and spoken English.

• Strong communication skills, both written and verbal.

• Ability to meet performance and attendance standards.

• Compliance with PacificSource privacy policy and HIPAA laws and regulations.

• Willingness to travel approximately 10% of the time.

🏝️ Benefits

• Opportunity to achieve Certified Case Manager (CCM) certification within two years, preferred, or complete 60 CEUs in Utilization Management focused areas.

• Access to employee education, onboarding, and ongoing education programs.

• Commitment to equal opportunity employment.

• Continuous improvement and professional development opportunities.

• Work in a general office environment equipped with ergonomically configured equipment.